Service Integration: An Overview of Policy Developments. (Issues in Perspective)

Article excerpt

During the 1990s, the rising prevalence of HIV and sexually transmitted infections (STIs) in low-income countries heightened international concern about the lack of means of control. The number of new HIV infections reached five million in 2001, of which 70% occurred in Sub-Saharan Africa, where more than 8% of adults are now infected. (1) The number of new STIs throughout the world totaled 340 million in 1999, (2) Because these infections contribute to the spread of HIV, (3) many HIV prevention efforts focus on managing STIs in addition to providing health education and promoting condom use. (4)

At the 1994 International Conference on Population and Development (ICPD), the international community made a commitment to providing a comprehensive package of reproductive and sexual health services, including management of HIV and STIs. (5) Particular emphasis was placed on controlling these infections through existing mainstream services--the maternal and child health and family planning services offered at most primary health care outlets in the developing world.

BACKGROUND

Advantages and Disadvantages

At first glance, HIV and STI control and women's reproductive health have much in common: Both are problems arising from sexual intercourse, and both rely on primary health care services currently used mainly by women. Within primary health care, maternal and child health and family planning services are relatively accessible in most low-income countries; thus, adding STI control appears financially and logistically rational. (6) Integration also capitalizes on the general interest in encouraging a more informed approach to sexual intercourse and its possible consequences. (7) Furthermore, where HIV and STI prevalence is high, family planning advice and methods should be appropriate to the disease environment and the associated sexual health risks.

The links between STIs and HIV transmission were confirmed in 1995, when a trial of STI treatment at the primary care level in Mwanza district in rural Tanzania reduced HIV incidence by 40%. (8) This trial relied primarily on syndromic management of STIs, an approach in which etiological diagnosis using laboratory support is rejected in favor of treatment for a range of common infections that might cause a particular set of symptoms. (9) The trial was particularly attractive because of its simple message, high impact on HIV transmission and relative cost-effectiveness. (10) As a result, policymakers became enthusiastic about implementing STI management programs in primary care, and "integration" became the mantra of governments and donors alike. (11)

Almost immediately, however, potential disadvantages of integration emerged. First, some thought it less effective than the traditional, vertical programs established during the 1980s. Designed to ensure efficient delivery of drugs and training, these programs focused on high-priority areas such as family planning or immunization. (12) Second, concerns arose that syndromic management increased costs and led to overtreatment, because some patients treated for the range of conditions that might cause their symptoms would not have all those diseases. (13) Third, there were fears that the stigma of HIV and STIs would lead to sensitivities between health providers and their clients. Finally, many acknowledged the difficulty of implementing a wide variety of new and clinically complex activities.

Furthermore, there are significant but overlooked discrepancies between the health care provided in the Tanzania trial and that found at most primary health care clinics in Sub-Saharan Africa. First, the trial included men, for whom the syndromic approach is known to be more effective than for women. Up to 75% of women with STIs have no symptoms, (14) so a treatment that relies on symptom management will not meet their needs. In addition, the vaginal discharge algorithm used in the trial was not particularly sensitive or specific to infection. …